Research leads to new surgical guidelines for parathyroidectomy.

Tertiary hyperparathyroidism occurs more than primary or
secondary hyperparathyroidism but it is rare and is seen in patients with renal
disease and post kidney transplant. Because it is a rare problem, guidelines
for surgical treatment and prognosis have not been well repeated in the past.
This study establishes guidelines for parathyroid surgical intervention.

In a scholarly and systematic review, Dr. Michael Friedman
and associates studied outcomes of hundreds of patients with tertiary
hyperparathyroidism who underwent a parathyroidectomy (removal of the
parathyroid gland). Control of symptoms and hypercalcemia cure rates were as
high as 94% in many studies.

Review methods: A systematic literature search was performed
using the. Original research articles in English were retrieved using the
search terms (“tertiary hyperparathyroidism” OR “3HPT”) AND
“parathyroidectomy”. Articles were analyzed regarding their surgical
indications, operative endpoints, comparison between different surgical
interventions, characterization of disease recurrence rates, and evaluation of
alternative medical management.

Results: Thirty studies met the criteria for inclusion.
Among the studies that report indications for parathyroidectomy, persistent
hypercalcemia as well as clinical manifestations of hypercalcemia despite
medical therapy predicted which patients would eventually need surgical
intervention. Most studies comparing the extent of parathyroidectomy
recommended a more focused approach to parathyroidectomy when warranted. All
studies found that parathyroidectomy was an effective treatment for 3HPT. Three
studies discussed alternative conservative approaches.

Conclusion: Interestingly, hyperparathyroidism alone is not
an indication for surgery without other findings; rather, symptomatic
hypercalcemia appears to be the main indication. Most studies recommend limited
or subtotal parathyroidectomy for 3HPT. The operative endpoint of surgery is
not necessarily a return of PTH to normal, but a N50% drop in PTH level even if
PTH remains above normal.

Additionally, “success” or “cure” is defined as normal
calcium levels regardless of whether PTH is elevated. It appears the goal of
surgery for 3HPT is not a normal PTH value, but a normal calcium level at least
six months postoperatively.